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Martino DJ, Valerio MP. Revisiting the concept of bipolar depression: comparison of diagnostic validators between melancholic and non-melancholic episodes. Eur Arch Psychiatry Clin Neurosci 2024; 274:507-514. [PMID: 36583740 DOI: 10.1007/s00406-022-01546-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022]
Abstract
The current definition of bipolar disorder derives with minimal changes from one that emerged through expert consensus in the late 1970s, and the topic of its validity tended to be neglected in the literature. The aim of this exploratory study was to compare patients with bipolar disorder with a history of melancholic and non-melancholic depressive episodes in a series of external diagnostic validators. One hundred eight subjects were categorized as melancholic or non-melancholic in relation to their history of depressive episodes through the clinician-rated Sydney Melancholia Prototype Index (SMPI). The external validators used were clinical-demographic variables, family history of bipolar disorder, neurocognitive performance and functional outcome. There were 43.5% of the patients with a history of melancholia and 56.5% of non-melancholic depression. Non-melancholic depressions were overrepresented in females, while melancholic depressions had a female:male ratio closer to unity. Patients with melancholia had more history of BD in first-degree relatives and better functional outcome than those with non-melancholic depression. There were no differences between groups regarding neurocognitive performance. Results tended to be unchanged when controlled for confounders. Our preliminary results highlight the inherent heterogeneity in the current concept of bipolar depression, and suggest the need for further clinical research to elucidate its validity.
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Affiliation(s)
- Diego J Martino
- National Council of Scientific and Technical Research (CONICET), Godoy Cruz, 2290, Buenos Aires, Argentina.
- Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University. Pacheco de Melo 1854, Buenos Aires, Argentina.
| | - Marina P Valerio
- National Council of Scientific and Technical Research (CONICET), Godoy Cruz, 2290, Buenos Aires, Argentina
- Psychiatric Emergencies Hospital Torcuato de Alvear, Av. Warnes 2630, Buenos Aires, Argentina
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Jansson Å. From Melancholia to Depression: Disordered Mood in Nineteenth-Century Psychiatry. HISTORY OF PSYCHIATRY 2022; 33:47-64. [PMID: 35090349 DOI: 10.1177/0957154x211062539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
My book From Melancholia to Depression: Disordered Mood in Nineteenth-Century Psychiatry charts how melancholia was reconceptualized in the nineteenth century as a modern mood disorder and a precursor to clinical depression. The book shows how this occurred chiefly in two ways. First, the idea of disordered mood as a medical concept was created through the appropriation of language from experimental physiology into the realm of psychopathology. Second, the interplay of statistical and diagnostic practices formed the basis for modern psychiatric classification and facilitated the standardization of melancholia as a psychiatric diagnosis. These developments were key to the reconceptualization of melancholia and the subsequent emergence of clinical depression, and were foundational to modern psychiatric theory and practice.
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Undurraga J, Vázquez GH, Tondo L, Baldessarini RJ. Antidepressant responses in direct comparisons of melancholic and non-melancholic depression. J Psychopharmacol 2020; 34:1335-1341. [PMID: 32900262 DOI: 10.1177/0269881120953983] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Efforts to develop less heterogeneous, more clinically useful diagnostic categories for depressive disorders include renewed interest in the concept of melancholia (Mel). However, clinical or biological differentiation of Mel from other (nonMel) episodes of depression has been questioned, and it remains unclear whether pharmacological responses proposed to be characteristic of Mel are supported by available research. METHODS We carried out a systematic review seeking treatment trials reports comparing Mel and nonMel depressed subjects for meta-analyses of their differences in responses (a) to antidepressants overall, (b) to tricyclic (TCAs) or serotonin-enhancing agents (serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors) and (c) with placebo treatment. RESULTS We identified 25 trials in 16 reports comparing 2597 Mel with 5016 nonMel subjects. Overall, responses to antidepressant treatment did not differ between Mel (39.4%) and nonMel (42.2%) subjects. However, all subjects responded better to TCAs (50.6%) than SRIs (30.0%; p<0.0001). Mel subjects also responded less well with placebo, but also were significantly more severely depressed at intake. CONCLUSIONS Antidepressant responses were similar in Mel and nonMel depressed patients. Mel subjects responded 25% less with placebo but were more severely depressed initially, and there was preferential response to TCAs in both Mel and nonMel subjects. The findings provide little support for proposed differences in responses to particular treatments among Mel versus nonMel depressed patients, and underscore the need to match for illness severity in making such comparisons.
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Affiliation(s)
- Juan Undurraga
- International Consortium for Mood and Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, USA.,Department of Neurology and Psychiatry, Faculty of Medicine, Clinica Alemana Universidad del Desarrollo, Santiago, Chile.,Early Intervention Program, Instituto Psiquiátrico Dr. J. Horwitz Barak, Santiago, Chile
| | - Gustavo H Vázquez
- International Consortium for Mood and Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, USA.,Department of Psychiatry, Queens University School of Medicine, Kingston, Canada
| | - Leonardo Tondo
- International Consortium for Mood and Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, USA.,Centro Bini Mood Disorders Centre, Cagliari, Sardinia, Italy.,Department of Psychiatry, Harvard Medical School, Boston, USA
| | - Ross J Baldessarini
- International Consortium for Mood and Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, USA.,Department of Psychiatry, Harvard Medical School, Boston, USA
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Tondo L, Vázquez GH, Baldessarini RJ. Melancholic versus Nonmelancholic Major Depression Compared. J Affect Disord 2020; 266:760-765. [PMID: 32217259 DOI: 10.1016/j.jad.2020.01.139] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/03/2019] [Accepted: 01/25/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The concept of melancholia has been associated with psychiatric nosology for centuries. Nevertheless, its definition, relationship to the contemporary concept of Major Depressive Disorder, and clinical implications remain uncertain. METHODS In a total sample of 3211 closely evaluated patient-subjects diagnosed with DSM-5 Major Depressive or Bipolar Disorder and meeting DSM-5 criteria for major depression with melancholic features or not at a European mood disorder center, we matched 1833 for depression severity (baseline HDRS21 score ≥18) and compared rates and ratings of characteristics of interest between the subgroups, using bivariate and multivariate methods. RESULTS Observed prevalence of melancholic features was 35.2% in the 1833 subjects matched for severity, and 21.0% among all 3211 subjects. Diagnosis was highly dependent on depression-severity measured three ways. Very few clinical characteristics differed between melancholic and nonmelancholic subjects matched for illness-severity; more suicidal ideation with melancholic features was a notable exception. CONCLUSIONS Study findings leave the distinction of melancholic features from depression-severity unclear and the potential clinical value of diagnosing melancholic features uncertain.
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Affiliation(s)
- L Tondo
- International Consortium for Mood & Psychotic Disorders Research, McLean Hospital, Belmont, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States; Lucio Bini Mood Disorders Centers, Cagliari and Rome, Italy.
| | - G H Vázquez
- International Consortium for Mood & Psychotic Disorders Research, McLean Hospital, Belmont, MA, United States; Department of Psychiatry, Queen's University School of Medicine, Kingston, Ontario, Canada
| | - R J Baldessarini
- International Consortium for Mood & Psychotic Disorders Research, McLean Hospital, Belmont, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States
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Abstract
We sought to identify clinical features that best discriminate melancholia from nonmelancholic depressive conditions. An extensive review of studies using latent factor models that identified a melancholic depression dimension/factor was undertaken. Clinical variables extracted from these studies were analyzed in terms of their contribution to a diagnosis of melancholia and their consistency across studies. Psychomotor retardation and mood nonreactivity were the most relevant clinical features for the identification of melancholic depressions. Other clinical features commonly described as weighted to melancholia, such as anhedonia, psychomotor agitation, late insomnia, or appetite/weight loss, seemed less useful in distinguishing these subtypes of depression. Study results are considered in relation to the potential limitations of current operational definitions of melancholia, and how symptom sets could be modified.
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Davey CG, Chanen AM. The unfulfilled promise of the antidepressant medications. Med J Aust 2017; 204:348-50. [PMID: 27169968 DOI: 10.5694/mja16.00194] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 03/17/2016] [Indexed: 11/17/2022]
Abstract
Australia has one of the highest rates of antidepressant use in the world; it has more than doubled since 2000, despite evidence showing that the effectiveness of these medications is lower than previously thought. An increasing placebo response rate is a key reason for falling effectiveness, with the gap between response to medications and placebo narrowing. Psychotherapies are effective treatments, but recent evidence from high-quality studies suggests that their effectiveness is also modest. Combined treatment with medication and psychotherapy provides greater effectiveness than either alone. The number of patients receiving psychotherapy had been declining, although this trend is probably reversing with the Medicare Better Access to Mental Health Care initiative. Antidepressant medications still have an important role in the treatment of moderate to severe depression; they should be provided as part of an overall treatment plan that includes psychotherapy and lifestyle strategies to improve diet and increase exercise. When medications are prescribed, they should be used in a way that maximises their chance of effectiveness.
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Affiliation(s)
- Christopher G Davey
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
| | - Andrew M Chanen
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
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Affiliation(s)
- Gordon Parker
- School of Psychiatry, University of New South Wales and Black Dog Institute, Randwick, NSW, Australia
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A meta-analysis of cognitive performance in melancholic versus non-melancholic unipolar depression. J Affect Disord 2016; 201:15-24. [PMID: 27156095 DOI: 10.1016/j.jad.2016.04.039] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/16/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recently there is increasing recognition of cognitive dysfunction as a core feature of Major Depressive Disorder (MDD). The goal of the current meta-analysis was to review and examine in detail the specific features of cognitive dysfunction in Melancholic (MEL) versus Non-Melancholic (NMEL) MDD. METHODS An electronic literature search was performed to find studies comparing cognitive performance in MEL versus NMEL. A meta-analysis of broad cognitive domains (processing speed, reasoning/problem solving, verbal learning, visual learning, attention/working memory) was conducted on all included studies (n=9). Sensitivity and meta-regression analyses were also conducted to detect possible effects of moderator variables (age, gender, education, symptom severity and presence of treatments). RESULTS MEL patients were older and more severly depressed than NMEL subjects. The MEL group was characterized by a worse cognitive performance in attention/working memory (ES=-0.31), visual learning (ES=-0.35) and reasoning/problem solving (ES=-0.46). No difference was detected in drug-free patients by sensitivity analyses. No effect was found for any of our moderators on the cognitive performance in MEL vs NMEL. CONCLUSION Our findings seem to support a moderate but specific effect of melancholic features in affecting the cognitive performance of MDD, in particular as regards visual learning and executive functions.
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Lieblich SM, Castle DJ, Pantelis C, Hopwood M, Young AH, Everall IP. High heterogeneity and low reliability in the diagnosis of major depression will impair the development of new drugs. BJPsych Open 2015; 1:e5-e7. [PMID: 27703745 PMCID: PMC5000492 DOI: 10.1192/bjpo.bp.115.000786] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 09/08/2015] [Accepted: 10/16/2015] [Indexed: 12/17/2022] Open
Abstract
SUMMARY Major depressive disorder is a common diagnosis associated with a high burden of disease that has proven to be highly heterogeneous and unreliable. Treatments currently available demonstrate limited efficacy and effectiveness. New drug development is urgently required but is likely to be hindered by diagnostic limitations. DECLARATIONS OF INTEREST D.J.C. has received grants and personal fees from Eli Lilly, Janssen-Cilag, Roche, Allergen, Bristol-Myers Squibb, Pfizer, Lundbeck, AstraZeneca, Hospira, Organon, Sanofi-Aventis, and Wyeth during the writing of this review. C.P. has received grant support from Janssen-Cilag, Eli Lilly, Hospira (Mayne), AstraZeneca, and received honoraria for consultancy to Janssen-Cilag, Eli Lilly, Hospira (Mayne), AstraZeneca, Pfizer, Schering Plough, and Lundbeck. Over the past 2 years he has participated on advisory boards for Janssen-Cilag and Lundbeck, and received honoraria for talks presented at educational meetings organised by AstraZeneca, Janssen-Cilag and Lundbeck. M.H. has received personal fees or grants from Lundbeck, AstraZeneca and Servier during the writing of this review. A.H.Y. reports personal fees from Lundbeck, Sunovion, AstraZeneca and Janssen outside the submitted work. I.P.E. has received personal fees or grants from Lundbeck, AstraZeneca, and Abbvie during the writing of this review. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
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Affiliation(s)
- Samuel M Lieblich
- , MBBS, MPsych, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - David J Castle
- , MD, FRANZCP, St Vincent's Hospital Melbourne and The University of Melbourne and Faculty of Health Sciences, Australian Catholic University, Melbourne, Australia
| | - Christos Pantelis
- , MD, MRCPsych, FRANZCP, Melbourne Neuropsychiatry Centre, The University of Melbourne and Melbourne Health and Florey Institute for Neuroscience & Mental Health, Melbourne, Australia, and Bedfordshire Centre For Mental Health Research in Association with the University of Cambridge, UK
| | - Malcolm Hopwood
- , MD, FRANZCP, Professorial Psychiatry Unit, Albert Road Clinic, and University of Melbourne, Melbourne, Australia
| | - Allan Hunter Young
- , Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Ian P Everall
- , BSc (Hons), MB ChB (Hons), PhD, DSc, FRCPsych, FRANZCP, FRCPath, Department of Psychiatry, University of Melbourne, Melbourne, Australia
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Möller HJ, Bandelow B, Bauer M, Hampel H, Herpertz SC, Soyka M, Barnikol UB, Lista S, Severus E, Maier W. DSM-5 reviewed from different angles: goal attainment, rationality, use of evidence, consequences--part 1: general aspects and paradigmatic discussion of depressive disorders. Eur Arch Psychiatry Clin Neurosci 2015; 265:5-18. [PMID: 25119146 DOI: 10.1007/s00406-014-0520-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 08/01/2014] [Indexed: 01/01/2023]
Abstract
DSM-5 was published in 2013 after about 10 years of preparation. Part 1 of this paper discusses several more general aspects of DSM-5 and offers a detailed, paradigmatic analysis of changes made to the chapter on depressive disorders. The background for the changes is analysed on the basis of a PubMed search and review papers on the classification of mental disorders in general and on empirical knowledge about individual disorders. Contrary to the original plans, DSM-5 has not introduced a primarily dimensional diagnostic system but has widely preserved the categorical system of disorders. Also, it has not adopted a more neurobiological approach to disorders by including biological markers to increase the objectivity of psychiatric diagnoses but has maintained the primarily symptom-based, descriptive approach. The criteria for some disorders have been changed, including affective, schizophrenic and addiction disorders, and a few new disorders have been added. A minimal version of the dimensional approach was realised through the introduction of several transnosological specifiers and the option to make symptom- or syndrome-related severity and dimensional assessments. These specifiers and assessments might allow a more individualised description of a patient's psychopathological state and more personalised treatment. However, most of the symptom- and syndrome-related assessments are not mandatory and therefore may not be used in clinical practice.
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Affiliation(s)
- Hans-Jürgen Möller
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany,
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Abstract
The fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 defines mental disorders as syndromes and also introduced disorder "specifiers" with the aim of providing increased diagnostic specificity by defining more homogeneous subgroups of those with the disorder and who share certain features. While the majority of specifiers in DSM-5 define a specific aspect of the disorder such as age at onset or severity, some define syndromes that appear to meet the DSM-5 definition of a mental disorder. Specifically, melancholia is positioned in DSM-5 as a major depressive disorder (non-coded) specifier, while catatonia is listed as both a disorder secondary to a medical condition and as a specifier associated with other mental disorders such as schizophrenia, major depressive disorder, and bipolar disorder. Despite decades of research supporting melancholia's status as a categorical "disorder" (a higher-order construct than a specifier), failure to provide convincing support for its disorder status has contributed to its current positioning in DSM-5. As DSM-5 has similar symptom criteria for major depression and for its melancholia specifier, research seeking to differentiate melancholic and non-melancholic depression according to DSM-5 criteria will have limited capacity to demonstrate "melancholia" as a separate disorder and risks melancholia continuing to be reified as a low-order specifier and thus clinical marginalization. There have been few advances in catatonia research in recent years with its positioning largely relying on opinion and clinical observation rather than on empirical studies.
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Affiliation(s)
- Gordon Parker
- University of New South Wales, Randwick, Sydney, Australia,
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Carroll BJ. ICD-11 and operationalism: response. Aust N Z J Psychiatry 2014; 48:781. [PMID: 24577067 DOI: 10.1177/0004867414526286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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A Historical Consideration of Psychiatric Diagnostic Systems : Focusing on the Concept of Depression. ACTA ACUST UNITED AC 2014. [DOI: 10.4306/jknpa.2014.53.5.259] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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